1548298565 NPI number — MID NORTH MEDICAL GROUP S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548298565 NPI number — MID NORTH MEDICAL GROUP S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID NORTH MEDICAL GROUP S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548298565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2740 W FOSTER AVE
Provider Second Line Business Mailing Address:
SUITE #210
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-989-2300
Provider Business Mailing Address Fax Number:
773-989-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2740 W FOSTER AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-989-2300
Provider Business Practice Location Address Fax Number:
773-989-2307
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUNI
Authorized Official First Name:
HARESH
Authorized Official Middle Name:
MUKUND
Authorized Official Title or Position:
M.D
Authorized Official Telephone Number:
773-989-2300

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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